Quality Reviewer (Aetna SIU)

At CVS Health, we’re building a world of health around every consumer and surrounding ourselves with dedicated colleagues who are passionate about transforming health care.

As the nation’s leading health solutions company, we reach millions of Americans through our local presence, digital channels and more than 300,000 purpose-driven colleagues – caring for people where, when and how they choose in a way that is uniquely more connected, more convenient and more compassionate. And we do it all with heart, each and every day.

Position Summary

• Assess the thoroughness and accuracy of investigations aimed at preventing payment of fraudulent claims by insured individuals, providers, claimants, etc.
• Analyze and prepare cases for clinical and legal review, ensuring all documentation meets required standards.
• Document all relevant case activity in the case tracking system.
• Evaluate and present referrals, both internal and external, within the required timeframe.
• Support the recovery of company funds lost due to fraud by providing insights and recommendations based on case reviews.
• Collaborate with the team to identify resources and the best course of action for ongoing investigations.
• Work with federal, state, and local law enforcement agencies to ensure compliance and support the prosecution of healthcare fraud and abuse matters.
• Demonstrate a high level of knowledge and expertise during interactions and provide confident testimony during civil and criminal proceedings.
• Deliver presentations to internal and external stakeholders regarding healthcare fraud matters and the organization’s approach to combating fraud.
• Provide input on controls for monitoring fraud-related issues within business units.
• Exercise independent judgment and utilize available resources and technology to develop evidence supporting allegations of fraud and abuse.
• Utilize company systems to obtain necessary electronic documentation.

Required Qualifications

• A minimum of 3 years of experience in healthcare within auditing, compliance, or fraud, waste and abuse.
• Knowledge of CPT/HCPCS/ICD coding.
• Proficiency in Microsoft Word, Excel, Outlook, database search tools, and internet research.
• Willingness to travel and participate in legal proceedings, arbitrations, depositions, etc.

Preferred Qualifications

• Credentials such as a certification from the Association of Certified Fraud Examiners (CFE), an accreditation from the National Health Care Anti-Fraud Association (AHFI), or a minimum of three years of Medicaid Fraud, Waste, and Abuse review experience.
• Billing and Coding certifications such as CPC (AAPC) and/or CCS (AHIMA).
• Knowledge of Behavioral Health policies and procedures is a plus.
• Experience reviewing Behavioral Health fraud cases.
• Understanding of clinical issues related to healthcare.
• Strong communication and customer service skills.
• Ability to effectively interact with diverse groups of people at various levels in any situation.
• Strong analytical and research skills using healthcare data.
• Proficient in researching information and identifying relevant resources.

Education

• A Bachelors degree or three years of experience in healthcare fraud, waste, and abuse investigations and audits.

Anticipated Weekly Hours

40

Time Type

Full time

Pay Range

The typical pay range for this role is:

$43,888.00 - $102,081.00

This pay range represents the base hourly rate or base annual full-time salary for all positions in the job grade within which this position falls.  The actual base salary offer will depend on a variety of factors including experience, education, geography and other relevant factors.  This position is eligible for a CVS Health bonus, commission or short-term incentive program in addition to the base pay range listed above. 
 

Our people fuel our future. Our teams reflect the customers, patients, members and communities we serve and we are committed to fostering a workplace where every colleague feels valued and that they belong.

Great benefits for great people

We take pride in our comprehensive and competitive mix of pay and benefits – investing in the physical, emotional and financial wellness of our colleagues and their families to help them be the healthiest they can be. In addition to our competitive wages, our great benefits include:

• Affordable medical plan options, a 401(k) plan (including matching company contributions), and an employee stock purchase plan.

• No-cost programs for all colleagues including wellness screenings, tobacco cessation and weight management programs, confidential counseling and financial coaching.

• Benefit solutions that address the different needs and preferences of our colleagues including paid time off, flexible work schedules, family leave, dependent care resources, colleague assistance programs, tuition assistance, retiree medical access and many other benefits depending on eligibility.

For more information, visit https://jobs.cvshealth.com/us/en/benefits

We anticipate the application window for this opening will close on: 04/07/2025

Qualified applicants with arrest or conviction records will be considered for employment in accordance with all federal, state and local laws.